With their increasing popularity, GLP-1 agonists, a class of prescription drugs, have been reshaping the conversation around weight loss. More than a fifth of Americans who have been told by a doctor that they are obese or overweight have taken a GLP-1 drug, a figure that doubles for those with diabetes. 

Surging interest in these drugs over the past several years has prompted many medical doctors and other clinicians to adjust their treatment plans for patients with obesity and Type 2 diabetes. According to the results of a Doximity poll, more clinicians now recommend patients start with a GLP-1 regimen alongside lifestyle changes (44% of clinicians) rather than start with lifestyle changes alone (33%).

“For many, but not all, people who live with obesity as a chronic disease, lifestyle changes alone may not be an effective long-term strategy,” Jennifer Manne-Goehler, MD, an internal medicine physician and infectious disease specialist, told Doximity. 

Dr. Manne-Goehler, who studies global obesity and diabetes epidemics and their interactions with HIV, has found that weight loss can be difficult to maintain through conventional diet and exercise, especially for those fighting the biology of their set point weight. And so GLP-1s, though not without their limitations, have emerged as welcome supplements to weight management efforts.  

Beyond the physiological effects, the rise of GLP-1s has also introduced new ways to view and discuss weight loss, obesity, and diabetes.

“GLP-1s have pulled these topics back to the surface and given us a way to talk about them and a tool to think about how we can address them,” Dr. Manne-Goehler said. “And that’s exciting, for both patients and doctors.”

GLP-1s or Lifestyle Changes

Across various medical professions, the poll results indicate that physicians are the most likely to prescribe GLP-1s alongside lifestyle changes for obesity and relevant medical conditions. About 46% of physicians recommend this dual approach to treatment, compared with 41% of NPs, 40% of PAs, and 39% of pharmacists. In contrast, about 30% of physicians recommend always starting with lifestyle changes, compared with 36% of NPs, PAs, and pharmacists.

Physicians are more likely to recommend starting with the lifestyle changes approach the earlier they are in their careers. The poll results show that 38% of residents and 37% of early-career physicians always recommend lifestyle changes first, falling to 33% for middle-career and 29% for late-career physicians.

Primary care physicians also tend to recommend lifestyle changes more often than specialists and are less likely to prescribe a combination of GLP-1s and lifestyle changes. For example, 58% of endocrinologists and 55% of cardiologists typically recommend the dual treatment approach, compared with 48% of family physicians and 42% of internists. In contrast, 32%-40% of geriatricians, pediatricians, family physicians, and internists always recommend starting with lifestyle changes, compared with 24%-26% of cardiologists and endocrinologists.

Early-career physicians as well as those in primary care may be more likely to start with lifestyle changes due to less familiarity with GLP-1s or because of their unique relationship with their patients. 

According to Dr. Manne-Goehler, many physicians also recognize the upstart barriers patients face with GLP-1s, including behavioral and financial limitations, and may hesitate to prescribe them at first.

“Yes, incretin mimetics [or GLP-1s] are quite effective,” said family physician Robert Rountree, MD. “But the immediate jump to prescribing them presumably occurs in a patient population that either has great insurance or lots of extra cash lying around.” 

Another family physician, Becky Chandler, MD, has seen numerous patients pull away from GLP-1s because of their high cost, potentially triggering consequences for their health and disease management goals down the line.

“I see patients every day dropping the biologic drugs,” Dr. Chandler said. “The big pharmaceutical companies need to significantly bring down their prices or allow us to get the compounded versions from reputable pharmacies.” 

Sustainable Care

What’s more, there are ongoing questions about the long-term implications of using GLP-1s. And experts in the field have emphasized the need to ensure obesity care stays sustainable amid the emergence of these drugs — but exactly how to do so remains unclear. 

Once patients achieve their immediate weight-loss goal, then questions arise about whether they should transition to maintenance with GLP-1s at a less frequent dose, a different class of drugs, or no pharmacological therapy; or if they should off-ramp through resistance exercise programs or by embracing food as medicine, according to Dr. Manne-Goehler, who has written extensively about the topic. 

“What is the evidence base for getting people safely tapered down from a high dose of GLP-1s?” she said, citing the potential long-term risks of suddenly stopping taking the drugs. “And for people who cannot do that without regaining weight and the cardiometabolic risk associated with it, what is the best approach for supporting adherence to these medications over the long term? We know nothing about how best to address those concerns.”

Still, the overall effectiveness of GLP-1s thus far has helped unravel some of the long-standing stigma surrounding obesity — opening the door to more honest conversations between patients and clinicians about the need for healthy weight management. In this way, patients can land on the most effective treatment plan together with their clinician. 

“We live in a world where weight is a huge issue that touches people in every facet of our culture, from pop culture to medical culture to our communities,” Dr. Manne-Goehler said. “So there’s a lot of reason for everybody to stop judging each other and recognize that this is a health struggle and that everybody’s answer is not necessarily the same.” 

To help carry this momentum forward, Dr. Manne-Goehler believes clinicians and researchers should continue studying this field with the long term in mind while making sure to equip front-line clinicians with key results as quickly as reasonably possible. 

“We don’t have the perfect answers yet, and it’s going to take several more years to really understand enough,” she said. “And I hope, really hope, our health system will help support that process.”

How do you use or prescribe GLP-1s in your practice? How do you discuss these drugs with your patients? Share in the comments!

Collage by Diana Connolly